1. ANORECTAL DISEASES Bernard M. Jaffe, MD Professor of Surgery, Emeritus
Tulane University School of Medicine

2. ANAL CANAL Borders- Coccyx Ischiorectal Fascia Bilaterally
Female- Perineal Body; Male- Urethra
Disorders Common and Generally Benign
BUT
Painful and Disabling
Divided Into Upper and Lower Segments

3. UPPER VS. LOWER UPPER LOWER Below Dentate Line Smooth Mucosa Absent
Above Dentate Line (Marked by Anal Valves)
Pleated, Folded Mucosa
12-14 Columns of Morgagni
Anal Crypts Between Columns
Cuboidal Epithelium
Below Dentate Line
Smooth Mucosa
Absent
Squamous Epithelium

4. ANAL SKIN Continuous with Anal Canal Contains Apocrine Glands
Site of Hydradenitis Suppurativa
Pain Receptors (Not Stretch)
Lesions Drain to Inguinal Nodes

5. VASCULAR Arterial Supply Bilateral, Duplicated
Middle and Inferior Hemorrhoidal Arteries Off Internal Iliac
Venous Drainage
Internal Iliac Veins to Inferior Vena Cava

6. ANAL MUSCULATURE One Tubular Structure Inside Another
Inner- Continuation of Rectal Circular Layer
Extends 1.5cm Beyond Dentate Line
Involuntary
Forms Internal Sphincter
Outer- Continuous Sheet of Striated Muscle of Pelvic Floor
External Sphincter
Voluntary Control

7. HEMORRHOIDS Abnormal Anal Cushions
Cushions Contain Blood Vessels, Smooth Muscle, Elastic and Connective Tissue
Left Lateral, Right Anterior, Right Posterior Positions
Unknown Causes, Includes Straining
Common During Pregnancy

8. EXTERNAL HEMORRHOIDS Covered by Anoderm Distal to Dentate Line
Swell, Causing Discomfort, Difficult Hygiene
Sever Pain Only with Thrombosis

9. INTERNAL HEMORROIDS Cause Painless Bright Red Bleeding
Prolapse with Defecation
Mucus Secretion
Itching
Pain is Rare (No Mucosal Pain Receptors)

10. HEMORRHOID GRADES 1◦ Bleeding Diet
2◦ Prolapse, Bleeding Rubber Band Ligation
3◦ Prolapse with Hemorrhoidectomy or
Digital Reduction, or Rubber Band Bleeding Ligation
4.◦ Strangulation Urgent Hemorrhoidectomy

11. OFFICE TREATMENT Dietary Management (for All Grades) Fiber Supplements
Local Hygiene
Avoidance of Straining
Medication to Soften Stool
More Extensive- Rubber Band Ligation

12. HEMORRHOIDECTOMY Indications Failure of Conservative Measures
Prolapse Requiring Manual Reduction
Strangulation
Ulceration
Commonest Complications
Bleeding
Urinary Retention

13. ANAL FISSURES Almost Always Directly Posterior
If Not- STD’s, Crohn’s, Hydradenitis
Associated Findings-
Sentinal (External) Pile
Enlarged Anal Papilla
Causes Pain, Mild Bleeding
Responds to Sitz Baths, Bulking Agents

14. ABCESSES Originate in Intersphincteric Plane Usually From Anal Gland
If Progress Downward to Skin Causes Perineal Abcess
If Progresses to Other Sites
More Complicated
Harder to Treat

15. OTHER SITES OF ABCESS Intermuscular- Vertical Tracking
Supralevator- Vertical Tracking
Tough to Diagnose
Ischiorectal- Horizontal Tracking
Horseshoe- Circumferential Tracking

16. ABCESS TREATMENT Drainage is Critical
Superficial Abcess- Office Drainage
Attempt to Localize Site of Origin Within the Anal Lumen
Needle Localization or CT Imaging May Be Necessary to Localize More Complex Abcesses

17. OPERATIVE DRAINAGE OR Required for Complex (Horeshoe Abcess)
High (Supralevator) Abcess
Immunocompromised Patients
Patients With Systemic Symptoms

18. FISTULA-IN-ANO Complicates Anorectal Sepsis in 25%
Originates in Dentate Line in Anal Canal
Presents With Purulent Peri-Anal Drainage
Punctate Indurated Papule With Opening
Inner Opening Identified by Probing at Dentate Line from Drainage Site
May Have Multiple External Drainage Openings

19. TYPES OF FISTULAS Type 1- Intersphincteric Treated by Fistulotomy
Type 2- Transsphincteric
Type 3- Supersphincteric
Type 4- Extrasphincteric
Latter 3 Treated With Seton

20. SETON Monofilament Nylon or Rubber Band Passed Through Fistulous Tract
Causes Fibrosis and Allows Later (8-12 Weeks) Sphincterotomy Without Loss of Continence
Cutting (Progressively Tightening) Seton Also Acceptable Technique
Difficult Fistulas- Sliding Flap of Mucosa, Submucosa, and Muscle to Cover Internal Opening

21. DIFFICULT FISTULAS
Sliding Flap of Mucosa, Submucosa, and Muscle to Cover Internal Opening
Injection of Fibrin Glue Into Opening
Even With Multiple Openings, There is Generally Only One Internal Opening

22. PILONIDAL SINUS Midline Sacrocoxxygeal Skin Acute Abcess
Chronic Sinuses
Rarely Confused With Fistula-in-Ano
Related to Hair, Penetration of Granulation Tissue Into Sinuses
Disease of Young People
Treated by Excision

23. CONDYLOMA ACCUMINATUM
Peri-Anal Wart
Caused by Human Papilloma Virus
Associated With AIDS, Anal Intercourse
Difficult to Eradicate- Cautery
Podophyllin
Significant Risk of Epidermoid Carcinoma

24. HYDRADENITIS SUPPURATIVA
Chronic Inflammatory Process
Occurs in Peri-Anal Area and Other Hair- Bearing Areas
Most Likely Theory- Debris Occludes Apocrine Gland →Purulence → Rupture→ Subqu Infection
Organisms- Strep milleri, Staph aureus, epidermitis, and hominis

25. TREATMENT Antibiotics Drainage, Debridement
Fistulotomy (Distal to Dentate Line)
Wide Local Excision With Skin Graft
Difficult to Eradicate
30% Recurrence Rate
Association With Squamous Carcinoma

26. CROHN’S DISEASE Anorectal Disease in 20%
Jeopardizes Continence 2◦ Inflammation
Causes Fissures, Abcesses, Fistulas
Fistulas Proximal to Dentate Line
Can Be First Manifestation of Disease
Symptoms- Pain, Bleeding, Soilage, Poor Continence

27. TREATMENT CONSERVATIVE MANAGEMENT Treat Ileal Crohn’s Dsiease
Sitz Baths, Stool Softeners, Analgesics
Steroids, 6 M-P, Azothiaprine, Cyclosporine
Avoid Fistulotomy- If Needed, Use Seton
Difficult to Manage- Non-Resposive
Often Extensive

28. EPIDERMOID CARCINOMA Anal mass With Bleeding, Pruritis
Epidermoid, Basaloid, Cloacogenic, Mucoepidermoid Types
<3cm in Size
25% Superficial or in Situ
71% Deep Penetration, 25%Node Positive, 6% Distal Metastases
Increased Frequency in AIDS

29. TREATMENT Superficial Lesions <2cm- Local Excision
Remainder- Nigro Protocol (Radiation, 5-FU, Mitomycin)
Almost All Respond and

30. TREATMENT Superficial Lesions <2cm- Local Excision
Remainder- Nigro Protocol (Radiation, 5- FU, Mitomycin)
Almost All Respond and Disappear
APR for Failure of Nigro Protocol
Contraindication to RT, Chemo
Deep Invasion
Aggressive Lesion